Basic Information
| Provider Information | |||||||||
| NPI: | 1295928836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-COLUMBIA HEALTH SERVICE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 E 19TH ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412967760 | ||||||||
| FaxNumber: | 5412967619 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 E 19TH ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412967760 | ||||||||
| FaxNumber: | 5412967619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | ARBON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5412967760 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 208D00000X | 01 | TAXONOMY | OTHER |